Should nurses become doctors to save primary care?

And I say, if you want to be a doctor, go to medical school. I say that as a red-blooded, licensed, board-certified, AMA card carrying, guild mentality, protectionist physician.

But I am also a citizen, a patient, a taxpayer, a public health professional, and a member of the Institute of Medicine (IOM) of the National Academy of Sciences.

The IOM has recently issued a very controversial report entitled The Future of Nursing: Leading Change, Advancing Health.

You nurse readers are going to love this report; many of you physician readers may not. It may curl your hair, in case you have any left.

According to the October 2010 IOM press release:

“Nurses’ roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by healthcare reform and to advance improvements in America’s increasingly complex health system. … Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States, said the committee. … To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor’s degree to 80 percent by 2020, and double the number who pursue doctorates. … Regulatory and institutional obstacles — including limits on nurses’ scope of practice — should be removed so that the health system can reap the full benefit of nurses’ training, skills, and knowledge in patient care.”

How about that? Do you see some state legislative battles coming up?

Of course, mainstream physician and organized medicine influence within that committee was sparse. But let’s face it. If this means that primary care can be rescued by physicians, physician assistants, and nurses (so called “Noctors”) working together, so be it.

For a wide variety of reasons, primary care by U.S. MDs is threatened with extinction.

And the demise of primary care would be really bad for the country and its inhabitants.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Should nurses become doctors to save primary care? 41 comments

Nearing the end of medical school and I have rotated with other med students, residents, fellows, and attending physicians who were formerly trained as nurses, physician assistants, therapists, etc. The common theme was how much more prepared they were for independent practice and that they did not have to worry about barriers or have to move to states that allowed them to practice independently.

With so many new medical schools, branch campuses and increased class numbers, it is without question that other providers of the medical team should pursue medical school training to further their careers. Admissions committes can figure out ways to be creative in selecting more of these non-traditional students and could provide them with a solid background of medical knowledge and recognition of common things presenting uncommonly while building on their great foundation of clinical skills and compassion for patient-centered care.

Antigonos

I AM a “nurse practitioner”, or an “advanced practice nurse” because I am a certified nurse midwife. Even when I was in training in the mid-1960s I heard lots of twaddle about how nurses were going to leave the bedside for “better positions”; indeed, the origin of the degree program for nurses was to make them feel less “inferior” to doctors, not really to improve their education. NURSING CARE ISN’T THE SAME AS MEDICAL CARE. Nurses SHOULD be at the bedside, not assuming “leadership roles” and leaving the actual physical, day-to-day and hour-to-hour care of the patient to poorly educated ancillary staff. If a nurse wants to act like a doctor, he/she should go to medical school and leave nursing to those who want to do the work of caring for the patient instead of giving orders to someone else. BTW, I know many doctors who worked as nurses while in med school, and it is fascinating to see how much they appreciate the need for good nursing care when they change professions. All the doctors’ orders in the world are worthless if not carried out by nurses.

This is an interesting comment. Okay…….I gotta ask…..sheepishly….where does the practical “how” come in? And because you are always so honest…….(you know those questions patients are just dying to ask, but won’t…um…er…I don’t think there is a pun intended here….) I just can’t resist asking you. Yeah, been reading too much of Gawande…..made me want to hide under the bed when you saw a resident coming towards the you. Ack….just a little bit of cyberdrama goin’ on…..um………:)

I enjoy your comments and your discussions. Can you rephrase your question? I’m not sure what you are asking. Perhaps you’re asking where does the practical knowledge come from? If that’s your question, I’d say the foundation comes from book learning, some of which you can get in medical school. The rest comes from things like on-the-job personal observations, informal brainstorming groups and formal journals. Those are all wonderful things because learning is one of the greatest activities we can all do in life and that we should never stop doing. There’s so much to keep learning, even for us doctors who’ve been practicing for years.

It was the how-to approach using in suspecting patients. I read some stories from nervous residents putting on tubes, and doing difficult procedures for the first time…and it seemed old people were particularly susceptible. Dr. Atul Gawande shares a story about a conversation he had that really sent my mind reeling (below). We were weeks away from major surgery, so off went an email from me to the surgeon. His response was wonderful.

Here is just one excerpt from Gawande:
He is discussing residents, and how they mess up…but it’s part of the training for their future. He shares that the learning is often hidden behind drapes and elisions of language. Sharing that doctors protect their own families from residents because of their lack of experience, and then shares about a conversation he had with a health policy expert who felt patients were being lied to. The expert was questioning whether the chances that were taken were worth it for the gain of society. The, obvious, answer was yes, but ironically the scene unfolded with the author observing a bit of hypocrisy on this experts part:
Pg. 31 It would certainly be a graceful and happy solution…we’d ask patients-honestly, openly-and imagine though, and then they’d say yes. Hard to imagine, though. I noticed on the expert’s desk a picture of his child, born just a few months before, and a completely unfair question popped into my mind. “So did you let the resident deliver?” I asked.
There was silence for a moment. “No,” he admitted. “We didn’t even allow residents in the room.” [end]

anonymous

as a first year medical student, i have to say that constantly reading about how primary care will be taken over by nurses and pa’s is a huge deterrent to thinking about entering primary care. that is not about wanting prestige or specialty money and lifestyle. that is the fear that my potential services would be so devalued as to make paying back student loans and getting on with life after sacrificing my 20s virtually unattainable. i don’t want to end up like the student who is six figures in debt from an undergraduate degree in film and defaulting on loans. in that context (overplayed in my head or not) the only safe choice appears to be specializing.

MS-0

Funny, as future physician (just accepted to med school) who aspires to pursue primary care, this was the same reaction that I had. It is a sad thought that as physicians we may all end up as specialists and technicians in order to keep our jobs.

Sandra

Hey, kids, this topic is being totally misperceived and unduly sensationalized. I’ve been a primary care internal med doc for 22 years, currently with Kaiser.. What I and other vets have found (if we’re honest with ourselves) is that 1/3 to 1/2 of what has traditionally fallen onto the MD’s plate is actually requiring a lower skillset than MD-level training. We do need to shift that work to our RN, NP, PA, PT and MA teammates. I didn’t go to med school and residency and then further hone my skills for years and years, only to sit in an exam room with a patient with a cold or who hurt their knee yesterday or who wants skin tags frozen with liquid nitrogen. I am trained to help the truly ill, older folks with heart failure or dizziness or chest pain or a creatinine of 2.5 or hematocrit of 25. So, my view is I want RNs to step up and do the stuff that I find annoying and let me take care of the serious MD-level
stuff. There is an overwhelming number of patients in dire need of our services, no shortage there. So let’s forget all the BS about RNs and NPs putting primary care docs out of business because it is completely false.

This is a perfect example. Going back to my above comment, you would ask yourself: Is specializing vs primary care going to provide more of a contrast between the KNOWLEDGE (and skills) you acquire vs the PERMISSION you acquire as compared to if you didn’t go through medical school

In the past, when you became a doctor, you gained knowledge/skills and you also gained the monopoly permission to provide that level of healthcare.

Your knowledge advantage can never be eroded nor diluted, but your permission advantage certainly can. For example, if you go into primary care thinking that you will have access to secret knowledge and skills that a NP or PA can’t attain, then you are safe. But if you go into a career as a primary care M.D., thinking it will give you monopoly privilege over NP’s or PA’s who are able to learn sufficient skills to do close to what you do, then you are not as safe.

On the other hand, if you are a CT surgeon who does bypass surgery and the rules of the game change so that PA’s and NP’s are permitted to try their hand at it, you are still safe because it is now your skills and knowledge which make it difficult for others to complete.

Again, think of it in terms of your KNOWLEDGE advantage and in terms of you PERMISSION advantage and you will be able to see the world more clearly. Because in a perfect world, it should be skills and knowledge that matter, but we live in an imperfect non-free-market world. Good luck.

Primary Care Internist

NPs can currently bill medicare at 85% of the physician rate, and there is sentiment to increase that to parity. So i ask anyone in med school why on earth they would go into primary care???

Aside from possibly caring about the total lack of coordination between a clock-in-clock-out “advanced practice nurse” and a bunch of specialists who disown the patient, you’d have to be nuts to be a med student now and actually WANT to do primary care.

HJ

“Aside from possibly caring about the total lack of coordination between a clock-in-clock-out “advanced practice nurse” and a bunch of specialists who disown the patient, you’d have to be nuts to be a med student now and actually WANT to do primary care.”

When I got sick, it was my primary physician that disowned me and the specialist who coordinated my care,

I agree with Dr. Lundberg and Antigonos. I just posted on this topic yesterday http://tiny.cc/loby7.

Annonymous

As a consumer, it seems like primary care has already been taken over by nursing. More often than not, when you call the office, visit the office or even go to a scheduled appointment, the person of contact is the NP or an office RN. Only in specific cases (or if you ask repeatedly) are items elevated to an MD.

Of course, this is why those in-store “Quick Clinics” are popping up…

Cheapo

nurses should not leave nursing to do primary care, nurses are nurses, there is already a nursing shortage……, i’m tired of nurses and PA’s who get fast tracked into advanced patient care, MD’s study for 4 years of school(many times they have already done grad school and research), plus the horrendously rigourous residency, most MD’s don’t get to make any real money until well into their 40’s, if a nurse wants to do primary care, bust your brains, lose your salary and overtime , and go to medical school, and residency. I do not see a primary care shortage in new york, so last thing i need is more practioners, as far as I’m concerned there should be a primary care shortage, we are endlessly disrespected by insurance companies and medicare with bullcrap reimbursement, ridiculous regulation, at any time we can lose our livelihood for the most absurd reasons, if there was a shortage of us we wouldn’t subject to this garbage, bout time the PMD gets some R-E-S-P-E-C-T. my rant for the day,

jim m.d.

Many years ago as a F.P. resident I once commented to a floor nurse that I could not keep track of all the differences re. nursing degrees and their various “turf battles” (ASRN, BSRN, RN, MSN, degree and non degree programs, hospital schools of nursing etc.).
The response I received was prescient. It was ” we eat our young.”
Nurses are done devouring their own, now they’re after the real meat. And they have lots of evolutionary practice.
A herbivore dinosaur

Why don’t doctors like you respect nurses? After our daughter’s neck dissection a few months ago the nurses were at our beck and call. They would leave the room and on the way out ask me if there was anything else we needed. I went to the floor supervisor to boast on the care. When our surgeon asked about the residents, I said they were fine, but I didn’t see much of them. They are really busy, while the nurses gave us spectacular care. Of course, I lived there and the notes share that we were great to work with….and, yet, I really just have to say that doctors displaying attitudes about nurses (who often recognize the docs errors) is really discouraging.

Wombat MD

Alice, What would you have done with the residents if you had seen more of them? Ask them to change the IV bag? Residents are busy with many many more patients, whereas floor nurses are meant to stay at the bedside with a relatively few number of patients. Of course you would see more of the nurses. As a physician, I know that nurses are invaluable and provide nursing care that could not be paralleled by physicians. However, on the flipside, nurses aren’t meant or educated to provide the same type of care as physicians either. It’s not that I don’t respect nurses, but I’m frustrated when physicians are maligned for “not spending enough time with patients” as compared to nurses, when the roles of physicians and nurses, and the amount of hourly interaction with patients is inherently different.

The residents? I liked them very much, but I like our doctor even more. If I had seen the residents more? What would I have done? Bought them some Starbucks and had a nice chat! My only complaint was the resident didn’t use the morphine she was supposed to when she pulled the drain out of our daughter’s neck. Our daughter turned white and looked like she was going to pass out. Yes, practice makes perfect.

The goal of my post was that doctor’s come up with snide, smug remarks about nurses who are doing their grunt work. Sure you are busy, but some of the comments from doctors about nurses are pretty arrogant. And, yes, my daughter is a nurse…just, incase, you wondered why I care.

The busier doctor’s become the more they need the nurses, because as we both know the residents are just so rushed in and out a mistake can easily be made.

Mark

Just another reason none of us MD students want to go into primary care. Nice job, guys.

Mike

What will their malpractice insurance premiums be?

Doctor S

Um, isn’t there already a shortage of… nurses? Who’s going to fill that gap when they leave nursing to pursue primary care? Nursing assistants? X-ray techs? Primary care is a highly cerebral profession when practiced in the way it should be. I am not aware of any nursing program that could prepare someone for it. Quite honestly there are a lot of really good nurses, who are excel tremendously at being nurses, who do not have a clue about basic blood pressure medications. If the crux of healthcare is to be handed to people who have not gone to medical school, then a real crisis on our hands. The field will most certainly lose all respect, and patients will suffer.

Bottom line is, if you need more doctors, then train more DOCTORS. Yes that might mean letting more people into medical school. Well with Obama’s new healthcare plan, we can expect an even greater inundation to primary care, and all specialties too.

BTW, “noctors”? A hilarious new term to me although I shudder at the thought of using it with any legitimacy.

Cheapo

if there are noctors then what about all the nocturnists, how do you think they will feel….i gotta admit i love this site.

LE

Why are alternatives threatening? Are you certain that you do it better? Really sure? Ok, good. Nobody will do what you do as well as you do it, -but maybe they aren’t trying to. Perhaps you are using the wrong criteria to judge their abilities or intentions. Do they want to be primary care Doctors or maybe only provide primary care. For the sake of the health of your patients and communities please consider where your skills and knowledge are best utilized.

I cannot help but wonder, with the issues brought out by healthcare reform, the perceived demise of the primary care physician, and the possible elevation of nurses to leadership roles, if this is all some sort of class warfare against physicians. Doctors are seen as being wealthy and expensive with high status and influence and I am not sure that this sits well with certain segments of our society. Particularly, those of a more liberal progressive bend. Is it that nurses are being better utilized or that doctors are being put in their place?

Miranda

I think the comments from medical students are fascinating. I am in my second year of private family medicine practice. I am blessed to be the rare breed of person who loves my job. Yeah, I’m not rich (but can certainly pay all of the bills, including student loans) and my lifestyle sucks (got paged at 4 a.m. today), but it is still so rewarding I can’t imagine doing anything else – much like many of the teachers, social workers, religious leaders, and fire fighters I know.

My concern with nurses taking over as physicians is that too many nurses have been trained to do their job…..and nothing else. While I certainly have worked with some excellent nurses who I’m sure could do my job better than I could, many clock in, clock out, and take care of the bare minimum while they are there.

Residency was painful but I learned to work with no food, no sleep, no exercise, no bathroom breaks. Physicians do this. It’s beat into us. Just like professional athletes will play a game on a broken ankle and the really good actors will let the really good directors do some crazy things to get the perfect shot. Physicians aren’t the only hardworking people out there. It just seems like too many people in healthcare want the right to practice medicine without having to deal with all of the garbage.

I know if I didn’t have $200,000 in debt and next-to-nothing in my 401k at age 30 I’d be willing to take a pay cut for a better lifestyle. Maybe all these physician extenders are the way to get it done. Maybe all of my hard work was for nothing. Maybe I’ll be out of a job before I’m 50. But I know just like we need fire fighters to jump up at 4 a.m., and teachers and pastors to work for bare minimums, we need people who will work through lunch, act coherent with middle of the night pages, and add on a few more patients because it’s Friday and they can’t wait through the weekend with their vaginal discharge or nagging cough or heartburn. I just don’t know how much they’ll have to pay someone else to do that, and if in the end they’ll still need us boring old primary care docs to carry that load.

justin

I think we want smart providers to take care of us. When doctor nurses took the final MD licensing exam they did horribly.

ARNPs and PAs were intially sold to the system as ways to expand access in rural and underserved areas. Now we have PAs pushing for independent practice and nurses wanting to be doctors. Residencies in dermatology for nurses. It is all about money and nurses are looking for a back door into becoming a physician. If you want to be a doctor go to medical school.

How likely is it that once primary care noctors become fully accepted by the public that the next step is for there to be necialists?

Mark Hodges

I am a Nurse Practitioner. I work hard and need help from Doctors to do my job. What I have found is 1) Many doctors do not know much more than I do. 2) They call it the practice of medicine, because they are still practicing, they don’t have all the answers either. 3) Who in the hell would want to be a doctor? It is hard work. Surely you could have found something else to do if you were smart.

miranda

I realize that my comments seem anti-nurse. I am actually extremely pro-nurse, and in many ways think their training and attitude towards work-life balance and patient-focused care far exceeds those of physicians. However, once their shift is over, it’s sign out and move on to the rest of your life. While some primary care docs have set up a lifestyle that alloiws for that, most haven’t. Maybe nurses will do a better job at being doctors than doctors. However, I think patients will struggle with tighter boundaries and less access to their personal pcp. And thank god I had the opportunity to go to med school because I know there is no way I could do what nirses do.

Nurseleah

As a nurse for the past 8 years working critical care in hospitals around the country, the article you posted was interesting. First of all, let me say that with the amount of exhaustive training doctors must go through in order to practice medicine, and the astronomical cost of the education, I feel that most are grossly underpaid for their work, and that PCP’s especially get the short end of the stick when it comes to patient load and responsibility. It is easy to see how, once in the field, doctors take on more and more patients and responsibilities (becoming medical directors of care homes, taking call, clinics, etc.) in order to earn what they must feel they should be earning after all they go through for the title. However. In nearly a decade of work, I see all too often that many, MANY doctors are stretched way too thin, and their care of increasingly complex patients suffers to sometimes dangerously neglectful levels. Who is picking up the slack then, when your Afib patients aren’t anticoagulated, when your COPD’ers end up vented, when your alcoholics withdraw and seize because proper precautions aren’t taken? Um, that would be the nurses. Articles like the one you commented on aren’t so much about infringing on the highly specialized skills of MD’s, as they are addressing the need for more highly educated nurses, who sit on the frontline in acute care settings, managing increasingly elder populations with multitudes of meds and problems. Nurses should have a voice in collaborating with other health professionals and ‘assuming leadership roles in redesigning care in the United States,’ because we see firsthand every aspect of what works, and what does not. You write the article states that ‘Regulatory and institutional obstacles — including limits on nurses’ scope of practice — should be removed so that the health system can reap the full benefit of nurses’ training, skills, and knowledge in patient care.’ To a degree, in an overly broad way, this is true, at least so far as it could streamline some areas of the medical process. Not to the point where nurses determine a patients plan of care, or intubate and perform surgery, but yes, to the point where a nurse can follow some standard practices with at least SOME autonomy. (Do I really need an order for a MRSA swab screening? For a PT consult? And hey-by-the-way you might want some DVT prophylaxis on your post-op patient? Sheesh.) In the end, there is no replacement for a doctor. But in the current state of our overwrought healthcare system, there has to be the clarification that sharing some of the responsibility of patient care is not a threat to the integrity of your livelihood, but an asset to the overall management of today’s patients.

Sandra

Yay!! I agree with your comments 100%, i’m a primary care PCP.

Janel

Wow what a great conversation. I am a nurse practitioner and I believe we are a good solution to the shortage of PCMD. I also know my limits . When I believe a patient is beyond my knowledge base I gladly hand that patient to my collaborating physician. I respect his work and knowledge. Why should he be bogged down with a patient with managable HTN or a sinusitis?MY patients love the care I give and I am always honest about being a NP and I give them the option to see the physican. Where I work there is a huge population of low income, somali , Burmese and Nepali patient population and lets be honest no one does not want to work there. It took my company 1 year to fill a primary care physician position. It took them 3months to fill a NP position. We are a busy primary care practice that encounters many obstacles to providing good care. We go with limited lunch breaks and lack of time to finish our paper work. Physicians should not be scared of our positions but should embrace us and work with us. NP need physicians. We bring a different view to healthcare. Do not under estimate our experiences on the nursing floor before becoming nurse practitioners. I learned many things from patients, families ,nurses and physicians. I became a nurse because I believe it was a calling from God to help others. I decided to become a NP because I wanted to increase my knowledge and income. In nursing there is not many ways to increase your income. I have student loans as well.
Why dont medical schools enroll more students? Why are we not preparing our youth to be stronger in science so they can go to medical school?

Bobbo

Janel,

I completely agree with the idea of NPs handling the simpler cases, and believe the ideal may be an integrated practice, with mabye 2-3 NPs and and FP. You’re right that you don’t need 4 years med school + 3 years residency to identify a case of sinusitis or the flu. That way the NPs handle the basics, send the more complicated cases to the FP or IM doc, and everybody wins. You’d think the docs would like that too, as they end up with more interesting cases.

The problem becomes when NPs open up shop independently. This means a couple things could happen.
1. NP tries to do everything on their own and makes mistakes, not recognizing their limitations. This is a common complaint I have heard about NPs, that they are excellent within their scope but not aware of their limitations outside of it.
2. NP works within scope and refers everything else to specialists. This increases total specialty referals, increasing fragmentation of care and costs.

PAULMD

Janel,
Those additional medical students will all become specialists if there are specialist spots that would have them. If specialty residencies and fellowships dry up, we remaining specialists will have significantly more power in negotiations with ALL parties….can’t have that happen.

If the number of specialty training spots is kept the same or increased, then there will be more mouths to feed…and the overall price goes up as well. Damned if you do….

Pursuing primary care at this point is foolish and if it is suggested by a medical school that you pursue primary care, they are committing internal medical school malpractice on their students.

IndiepsychNP

NPs started came about in an omnibus spending act in Congress in the late 60s around the time of my birth because MDs did not want to go into rural areas to provide primary care. There was no money to be made there. Nurses filled the gap. However, NPs who choose that practice now are foolish. MDs may degrade whatever we
do, but why should we martyr ourselves because the AMA sold out primary care and internists?
Why should any young MD or NP put their future on the line because a huge generation about to
retire did not shore up a Medicare trustfund? Our student loans never came up in the “healthcare debates” between lawyers and health insurance companies. We need to be realistic about how we can provide care for patients, our families, and the student loan servicer from taking our tiny house away….

After the doctor walked into the room and stated, ‘She just won’t die!’ regarding my palliative client, I realized that one cannot compare physicians and nurses.

Our NP is much more approachable, and it simply makes sense in our integrated Family Health Team in Ontario. It is a team approach, with different levels of issues. I cannot be more pleased with the NP.

jsmith

To the young med students from a guy who has been a family doc for 21 years. Be very very leery of PC. If you slog away in the clinic, perhaps you will be replaced by doctornurse. Perhaps even someday doctornurse will be your boss! If you try to be superdoc and work in the hospital, too, and maybe do OB, your life will suck and you will still make less than you would have in a different specialty.
By its actions, America has shown that it simply does not want medical students to go into PC. Listen to your countrymen. Specialize.
To the nurses I say good luck with PC. May it would out better for you than it has for us.

imdoc

Study the Flexner report to learn this really is just history repeating itself…

Nurseleah

In today’s state of healthcare, this is such a necessary dialogue! (BTW, thank you, Sandra, and I wish you all the best in your practice!) Truly, if you start from the beginning and read through the commentary, the common denomenator is a flooded system and dysfunctional state of health care programs. If I may, I don’t think it is even really a case of ‘anti- or pro- nurse.’ For quite some time now, the nurses are the ever-present eyes and ears FOR the doctors, without which the physicians could certainly not extend their level of skill and care to the quantities of folks out there who need it. It is a symbiotic relationship, and in certain areas where a percentage of the population with common ailments frequently clogs up the system, so to speak, the advanced practice nurses have their place in the heirarchy, to screen and treat within their scope *in conjunction with* the physicians. I mean, certainly it can be touchy in a case-by-case look at how certain NP’s function… there can ALWAYS be the proverbial bad apple… But for the most part, as the population grows and medicine operates more and more on the ‘what’s best for the herd’ mentality, PCP’s seem to be freed up to do what they do BEST when the NP’s and PA’s reduce some of their workload. I can see how primary care is a dying breed, and how specializing is so much more desireable, the same way I can see how scheduled C-sections gave OB’s a little of their lives back. But maybe in order to revive the desire to go into primary care, a greater utilization of NP’s and PA’s will be necessary, if only to develop a system in which the workload is more evenly distributed, where PCP’s can function at a level, both professionally AND financially, that is fitting to their level of education. To ‘imdoc’, I found a summary of the Flexner report… Are you saying that the need for medical education reform is a contributing factor to all of this? Or are you saying that the system is being flooded with substandard medical care provided by NP’s?